Comparing Digital Replantation Versus Revision Amputation Patient Reported Outcomes For Traumatic Digital Amputations Of The Hand: A Systematic Review And Meta-analysis
Nicholas Stone, MD, Ajay Shah, MD (candidate), Brian Chin, MD, Victoria McKinnon, MD (candidate), MSt, Matthew C. McRae, MD, MHS, FRCSC.
McMaster University, Hamilton, ON, Canada.
Adults with traumatic digital amputation (TDA) of the hand may be surgically managed with replantation or revision amputation. Factors that influence surgical management include hand dominance, the injured digit involved (i.e. thumb vs. non-thumb) and the level of injury. The aim of this study is to determine whether revision amputation compared to replantation yields superior patient reported outcomes (PROs) and other clinician reported outcomes, with respect to TDA of the hand in adult patients. To date, there is no systematic review evaluating PROs in this population to suggest the optimal treatment approach depending on the level of injury and which digit is amputated.
Three databases (Medline, Embase, and PubMed) were systematically searched for English language literature from database inception until June 13, 2019 independently and in duplicate by two reviewers. Primary randomized and observational studies comparing replantation and revision amputation for isolated TDA in human subjects were considered for inclusion. Methodological quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Data were pooled in a random-effects meta-analysis model with subgroups based on level of injury and the digit(s) involved.
Of 4,350 studies identified, 12 retrospective cohort studies met inclusion criteria and compared outcomes of TDA treated with replantation (n=717; 80.2% male; mean age 40.3) versus revision amputation (n=1,046; 76.1% male; mean age 41.7). The overall replantation survival rate was 85.1%. The average MINORS score for included studies was 13.75/24 (57%, range 10-18). Only 3/12 included studies, with predominantly Asian patient populations, reported sufficient PRO data for meta-analysis using the Michigan Hand Questionnaire (MHQ) and Disability of Arm, Shoulder and Hand (DASH) data. Replantation of the thumb had a superior MHQ score (+12.01, 95% CI [7.96 to 16.07], I2=18%) compared to revision amputation without evidence of subgroup effect whether the injury was proximal or distal to the IP joint. Replantation of single non-thumb digits had a superior MHQ score (+5.32, 95% CI [3.11 to 7.53], I2=62.4%) and DASH score (-3.43, 95% CI [-6.75 to 0], I2=0%) compared to revision amputation.
There is significant heterogeneity in the reporting of outcome measures and methods of stratifying levels of TDA treatment. Among studies reporting PRO data, replantation had superior MHQ scores for all digits including the thumb and a superior DASH score for single non-thumb digits. However, the clinical importance of these differences is difficult to interpret in the absence of an established minimally important difference (MID) to contextualize the results. The MID for MHQ and DASH for patients with traumatic digital amputations is uncertain and may vary depending on geographic and cultural differences. Overall, the PRO outcomes demonstrate statistically superior results in favour of replantation which may or may not be clinically important. Future prospective studies that evaluate PROs with stratification based on level of injury are needed to suggest more specific treatment recommendations, in particular for North American populations which are underrepresented in this meta-analysis.
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